Davita Charlottesville North Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 45736 Based on observation, facility policy review and interview, the facility failed to ensure infection protocols were followed for hand hygiene to prevent the transmission of infections. The findings include: On December 29, 2025, during observations of care on the treatment unit between 10:30 AM and 12:00 PM, the surveyors observed the following missed opportunities for hand hygiene: Staff Member #1, did not perform hand hygiene before donning clean gloves and conducted a patient assessment. Staff Member #9, removed gloves, went to get clean supplies, returned to the patient station, did not perform hand hygiene, donned clean gloves and provided arteriovenous (AV) fistula initiation care. Then they removed their gloves, used the computer keyboard, did not perform hand hygiene, donned clean gloves and continued to provide AV fistula initiation care. Staff Member #10, did not perform hand hygiene prior to donning clean gloves while providing central venous catheter (CVC) initiation care. Staff Member #11 did not perform hand hygiene after removing dirty gloves and donning clean gloves while providing central venous catheter (CVC) exit site care. Additional observations were conducted on December 29, 2025, on the treatment unit between 1:45 PM and 2:30 PM, the surveyor observed the following missed opportunities for hand hygiene: Staff Member #10 removed dirty gloves, did not perform hand hygiene, went to obtain clean supplies, returned to the patient station, did not perform hand hygiene, donned clean gloves and provided CVC discontinuation care. Staff Member #10 gathered dirty supplies with gloves on, discarded the supplies in the trash can, removed dirty gloves, did not perform hand hygiene, donned clean gloves and continued to provided CVC discontinuation care. The facility policy, Infection Control for Dialysis Facilities, last revision April 2023, was reviewed and revealed, in part: “Hand Hygiene: 1. All teammates, Physicians, and non-Physician (NPP) will perform hand hygiene...b. prior to gloving and immediately after the removal of gloves...d. after patient and dialysis delivery system contact...g before touching clean areas such as supplies, supply cart, and chairside keyboard/mouse...” During an interview with Staff Member #4, the afternoon of December 29, 2025, they indicated that since taking over as the facility administrator in September 2025, hand hygiene is something they are working on. They are focusing on better hand hygiene practices with audits, daily home room reminders and monthly staff member meetings.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 45736 Based on observations, facility policy review and interview, the facility failed to follow their policy on appropriate use of PPE (personal protective equipment). The finding include: On December 29, 2025, during observations of care on the treatment unit between 10:30 AM and 12:00 PM, the surveyor observed the following: Staff Member #11, while wearing their PPE, went into the facility waiting room to escort a patient onto the treatment floor. Staff Member #10, while wearing their PPE, went into the facility waiting room to escort a patient onto the treatment floor. The facility policy, Infection Control for Dialysis Facilities, last revision April 2023, was reviewed and revealed, in part: “...PPE (i.e., gown, gloves, eye protection, face shield) 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. PPE is to be: a. Removed prior to leaving the treatment area...c. PPE is not to worn in non-treatment areas, for example, teammate lounge, teammate offices...” During an interview with Staff Member #4, the afternoon of December 29, 2025, they indicated that they also observed the staff members enter the waiting room during the surveyor’s observations and that this is not an acceptable practice. PPE is to be removed if entering the waiting room. If the staff members are only opening the waiting room door and calling a patient back, never going into the waiting room, PPE would not need to be removed.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 45736 Based on observations and facility document review, it was determined that the facility staff failed to maintain a safe environment for dialysis patients by not properly labeling medication syringes and not discarding an expired multi dose vial, according to facility policy. The findings include: On December 29, 2025, during observations of care on the treatment unit between 10:30 AM and 12:00 PM, the surveyor observed the following: Two (2) pre-drawn syringes of heparin were observed on a counter in the treatment unit. The syringes were labeled with staff initials but did not include the time the medications were drawn. One multi dose vial of Turbesol (used for tuberculosis testing) had an opened date of November 3, 2025. A review of the facility’s policy “Medication Policy”, revised October 2023, revealed, in part “...20...If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of teammate preparing the medication...29. Medications containing a preservative must be discarded 28 days after opening or accessed (e.g., needle punctured)...30. All medications in the facility are checked monthly. Insulin and other medications with preservatives are dated and initial once opened. All medications are checked monthly for expirations dates...””